In his preoperative discussion, Dr. White would have ensured that the patient understood basic aspects of his disease and of the operation. During this conversation, the patient did not express to Dr. White the same thought he later mentioned to the resident and student: that he only wants Dr. White to operate on him If he had, the surgeon would have explained that he could not do the operation by himself: assistants--residents, medical students, physician's assistants, or nurses--would be helping him. They would sometimes hold tissue aside to allow him to see the blood vessels, and would sometimes be cutting or sewing, according to the usual routine that he employs in all of his operations. He would be physically present at the operating table during all the critical parts of the operation and would be fully responsible for every aspect of the procedure.1 These are the very routines, he would have explained, that have led to his excellent surgical results. Nearly all patients gladly accept an explanation of this kind. If the patient insisted, however, that he and only he cut and sew, Dr. White would be bound to do just that (or to refer the patient to another surgeon).

Because medical students are not physicians, the patient should be made aware of their participation in operations: "In instances where the patient will be temporarily incapacitated (e.g., anesthetized) and where student involvement is anticipated, involvement should be discussed before the procedure is undertaken whenever possible."2 Dr. White probably introduced the resident and the student to the patient when they entered the room, but, failing that, his mention of student assistants would have satisfied this ethical guideline. The patient could ask for further discussion and could, if he wished, exclude students from participating in the operation.

The resident's response to the patient's question is inappropriate. The patient is naïve about operating room procedures, so the resident's succinct reply misled him into false beliefs: Dr. White would be the only one cutting and sewing, assistants do not perform these acts, and the student, merely "watching," would not be scrubbed at the operating table. In reality, the lines between roles are not nearly so plainly drawn in the operating room.

Because Dr. White did not talk with the patient about operating room personnel, the student was ethically obligated not to help close the incision, just as described in the above essay. Indeed, the student should not even be scrubbed in at the operating table; rather, she should watch the operation from the best available vantage point. When asked to help close, the student should demur, repeating the resident's comments to the patient. Dr. White should then excuse the student from participating further in the operation. Later, in private, he should have an edifying conversation with the resident, explaining how to talk with patients about surgical assistants.